A New Agenda for Optimizing Investments in Community Mental Health and Reducing Disparities

Universal school meal programs provide free breakfast and/or lunch to all students within a public school, usually through state administration of federal programs such as the National School Lunch Program. Longitudinal studies with assessments prior to program initiation and again after 4–6 months demonstrate that higher rates of student participation in school meals are associated with improvements in psychosocial outcomes, including reductions in hyperactivity, anxiety, and depression symptoms (22), and increases in psychosocial functioning scores via the Pediatric Symptom Checklist (23), as well as improvements in a range of academic outcomes, such as math scores and school attendance (22, 23). The impacts of universal school meals might also translate to economic benefits, as suggested by a study in Sweden using a difference-in-differences design (24), which found that students exposed to the program earlier and for longer experienced 3% higher lifetime income, with greater effects for youths from poor households. Although school meal programs are widely available, many youths who would benefit from them—particularly those from racial/ethnic minority or low-income backgrounds—do not participate unless these programs are open to all students in the school (i.e., “universal”) (25). Quasi-experimental evidence demonstrates that allowing students to eat in the classroom can also substantially increase school breakfast participation (73.7% participation in the intervention compared with 42.9% in the control group) (26). In 2021, California and Maine passed laws and budgets that fully fund breakfasts and lunches in all K-12 public schools for all students, regardless of family income (27). Massachusetts passed a similar law for schools or districts where the majority of students meet low-income criteria (28), highlighting that these efforts can be adopted at local and state levels. During the COVID-19 pandemic, the U.S. Department of Agriculture extended area eligibility waivers nationwide for summer meal programs, removing the requirement that universal child nutrition programs only be offered in “areas in which poor economic conditions exist.” The Universal School Meals Program Act of 2021 (S.1530) would remove area eligibility requirements year-round, making breakfasts and lunches free for all students in public schools. This bill was introduced in the Senate on May 10, 2021, and at the time of this writing was with the Committee on Agriculture, Nutrition, and Forestry. The mental health workforce can play a role in supporting these initiatives by screening for food insecurity and advocating for youths in their communities (29).

One intervention that could make a large improvement in disparities, such as possibly eliminating the racial wealth divide within a generation (30), is universal Child Development Accounts (CDAs). CDAs are savings accounts that are often started at birth, which the individual can access once they turn 18 to use for specific things such as paying for college, buying a home, or starting a business. Compared to children without CDAs, those from low- and moderate-income backgrounds who have CDAs have demonstrated improved socioemotional outcomes (e.g., self-regulation, compliance, and interaction with others) (31) and mental health outcomes (e.g., self-rated mental health functioning) (32). Youths randomized to receive CDAs were also three times more likely to attend college and four times more likely to graduate (33). Experts have theorized that parental attitudes and behavior may mediate the impact of the savings accounts on youths. There is evidence that CDAs can reduce mothers’ depression symptoms around 3 years after the intervention (34). Although already implemented with strong bipartisan support in 36 states (35), more long-term research is required to confirm CDA impacts on recipients’ mental health once they reach young adulthood.

Early childhood education and enrichment interventions, such as the Head Start and family-based ParentCorps programs, have been shown to aid the socioemotional development and academic achievement of children from low-income households (36). Such programs are also associated with reductions in child maltreatment (37), which helps mitigate risk of exposure to multiple forms of adversity. Aside from early childhood interventions, school-based mental health services have been shown to be particularly helpful for minoritized youths in urban and low-income neighborhoods (38). Benefits of tiered models include early identification of problems, followed by interventions and/or referrals. However, there is a lack of streamlined triaging of students with more serious behavioral health needs after identification. In response to this, Boston Public Schools launched the Comprehensive Behavioral Health Model (39) in 2012, which operates as a tiered system enhanced by partnerships with community-based behavioral health services. Longitudinal research from the universal screening database over 3 years finds that students in these schools—a majority of whom are Black and Latinx—demonstrate improvements in socioemotional, academic, and mental health outcomes within 1 year, which are sustained at 2 years (39, 40). In addition, universal interventions delivered in schools can be an effective strategy to combat mental health stigma and increase mental health literacy (41), which remain barriers to treatment seeking.

The potential of community-based organizations to play a crucial role in youth wellness cannot be overstated. Frazier and colleagues (42) developed a model of mental health consultation, training, and support of staff at recreational after-school programs delivered by paraprofessionals. An extension to this work resulted in the Fit2Lead program in Miami (43), a park-based program that offers after-school programming (e.g., academic, socioemotional, and life skills workshops) at no cost for youths living in disadvantaged neighborhoods. In a longitudinal study comparing zip codes matched by park and sociodemographic characteristics (60% Hispanic, 29% non-Hispanic Black, 33% of residents living in poverty), and after adjusting for covariates, the zip codes with Fit2Lead implementation had a mean reduction in the annual rate of youth arrests (ages 12–17) compared with zip codes without Fit2Lead implementation (44). In addition, Fit2Lead youths’ and parents’ mental health remained stable over the course of the school year (45), as opposed to declines commonly observed among adolescents and their parents living in Miami neighborhoods with high levels of community violence. This study demonstrated the promise of Fit2Lead in helping to disrupt a downward trend in mental health trajectories among Latinx and Black families. These findings suggest that task-shifting to paraprofessionals may be an effective way for the benefits of park-based after-school programs to reach a broader community.

Insecure housing and employment are two areas that have garnered attention in addressing mental health outcome disparities among underserved adult populations. For example, Housing First programs, without prerequisites of demonstrated substance abstinence or engagement in psychiatric treatment, were shown to lower homelessness by 88% and improve housing stability by 41% compared with Treatment First programs, which do require participants to be substance free and in psychiatric treatment (46). There is evidence that Housing First programs can contribute to small reductions in depression, emergency department use, hospitalization, and mortality among people living with HIV (46). More research is needed to examine whether Housing First programs in conjunction with voluntary mental health treatments can effectively reduce morbidity and mortality related to serious mental illness and/or addiction (47). Importantly, many housing policy interventions have worsened racial/ethnic inequities in social determinants of mental health, such as the displacement of Black families during implementation of the HOPE VI model (48); thus, Hernandez and Swope (48) highlight the need for health- and equity-specific outcome measures in the design of research evaluating housing policy.

Supported employment is one of few interventions that can reduce an individual’s dependence on the mental health system (49). Individual placement and support (IPS), the only evidence-based model of supported employment for people with serious mental illness (50), includes a rapid job search with an IPS specialist, competitive employment, and integration with mental health treatment, among other core principles. A meta-analysis of randomized trials (51) shows that IPS compared with treatment as usual leads to competitive employment within the short term. Compared to those in the control group, people in the IPS condition were three times more likely to work 20 hours or more per week and maintained employment for four times longer. Most studies have focused on vocational outcomes, but IPS has also been associated with sustaining mental health status and lower likelihood of mental health hospitalization (49), including among people with the most severe mental illness and people prone to crises. IPS has expanded to a wide range of populations, including people on the autism spectrum, people with substance use disorders, people with borderline personality disorder, and people with more common mental health conditions (50). There are at least 366 IPS programs in the United States and 100 outside the United States, thanks to a learning community of researchers and programs (50). However, implementation remains far behind demand. It is estimated that in the United States, approximately 60% of people with serious mental illness want to work but fewer than 2% have access to IPS (52). Access to IPS would be increased through the creation of a simple funding mechanism and revision of disability policies (52).

In addition to employment, income support programs have demonstrated mental health benefits. One example is the Stockton Economic Empowerment Demonstration (SEED), which aims to assist families with children through $500 monthly payments over a 2-year period. Preliminary results from a randomized controlled trial suggest reductions in maternal depression and anxiety (53). Another example of the mental health effects of expanded income policies is the Earned Income Tax Credit (EITC) for low-income adults, which reduces poverty, increases life expectancy (54), and decreases depressive symptoms among low-income women (55). Advance monthly payments of the Child Tax Credit have been linked to a reduction of 26% in household food insufficiency (56). A variation of the EITC implemented in New York City, Paycheck Plus, demonstrated promising results among low-income workers (57), with sustained improvements over time, including reductions in psychological distress among women and noncustodial parents (58). The uptake of EITC through the American Rescue Plan to citizens and lawfully present children, even if family members did not comply with certain immigration policies, decreased family poverty (59). However, even though income support policies may improve mental health outcomes (60), they may not influence the racial wealth gap without including a feature for wealth accumulation (61).

Help-seeking for common mental health conditions such as depression and anxiety often occurs within social-service or community organizations rather than health care settings, particularly in underresourced communities. Systematic reviews have identified mental health interventions delivered by paraprofessionals in community-based settings that demonstrate positive mental health outcomes (62). Barnett and colleagues (62) found that of 38 studies analyzed, 27 were randomized controlled trials, and in 69% of those, mental health outcomes were significantly better in the intervention group than in the control group. One community-based model to address social and clinical factors associated with depression is the formation of multisector coalitions, which are networks of health care and non–health care programs. An example of a coalition intervention is the Community Engagement and Planning program to support depression collaborative care, organized through the Community Partners in Care research team in Los Angeles (63). In a randomized trial, Community Engagement and Planning was more effective than the comparison intervention (technical assistance) in increasing rates of depression remission at 4 years (63).

There is also evidence that mental health literacy can be improved through community-wide interventions, such as awareness campaigns, informational materials online, and education-entertainment programs (64). Two examples of mental health literacy campaigns and tools designed for Spanish-speaking Latinx populations that have been rigorously tested and replicated in multiple studies include La CLAve (65) and “Secret Feelings” (66). In La CLAve, a 35-minute workshop, community health educators facilitate a discussion for community residents and family members based on a narrative film about signs of psychosis and help-seeking. Through a randomized controlled trial (67) and pretest-posttest evaluations (65, 68), the campaign has been shown to increase psychosis literacy of U.S. Latinx community residents. “Secret Feelings” is a fotonovela (i.e., a booklet telling a dramatic story with photographs and captions) designed to increase depression literacy, reduce stigma, and increase help-seeking behavior among Latinos. In experiments where adults were randomized to the fotonovela or a comparison condition (e.g., a text pamphlet about depression), the fotonovela group had greater reductions in stigma toward antidepressants and mental health care (69, 70) and greater improvements in self-efficacy related to identifying need for treatment (70). The “Secret Feelings” fotonovela was more likely than the pamphlet to be shared with family or friends after the study (69), and many participants in the La CLAve film focus groups also reported discussing the content of the film with others in their immediate social networks (71), demonstrating the ability of these literacy campaigns to reach throughout communities and promote dialogue about mental illness.

Green spaces (e.g., parks, gardens) and blue spaces (e.g., oceans, lakes) may help reduce racial/ethnic and socioeconomic disparities in mental health outcomes (72). For example, greater amounts of green space were associated with up to 37% lower odds of depression among older adults living in low-income neighborhoods (compared to 27% and 21% for those in medium- and high-income neighborhoods, respectively) (73). South and colleagues’ (74) cluster randomized trial of vacant lot greening is a good example of an experimental design capable of testing and demonstrating the benefits of green space exposure for adult mental health. It is also a good example of an innovative place-based intervention in low-income urban neighborhoods. Greater attention to how green/blue spaces specifically impact older adult mental health outcomes and disparities is warranted (75, 76). Observed improvements may be due in part to the increased opportunities for social interaction and physical activity that green/blue spaces provide (77). Indeed, a cross-sectional study evaluating data from 18 countries found little evidence for a direct association between green/blue spaces and mental health when recreational visits were accounted for in the models. This finding could suggest that one’s use of these spaces may be more important than one’s proximity and/or access to these spaces (78). Differences in the quality of green/blue spaces (e.g., rates of pollution, crime) may also explain the lack of a direct association, since individuals living in disadvantaged neighborhoods may not be able to access, utilize, and therefore benefit from these spaces to the same degree as individuals in more affluent neighborhoods. If true, an assessment of environmental quality and needed improvements would be an important preemptive step to promoting green/blue spaces in certain neighborhoods.

Overall, the promotion of social relationships and interactions is a recurring theme in the literature on improving healthy aging. Research suggests that feelings of isolation and loneliness are associated with a range of negative mental health outcomes (79), which may be exacerbated among older adults from racial and ethnic minority groups who face additional challenges in their pursuit of care (80). Further, some of the identified correlates and predictors of social isolation and loneliness disproportionately impact those from racial and ethnic minority groups and low-income backgrounds (81). While there is a need for development and evidence-based interventions targeting social isolation among older adult populations (82), the fact that many programs (such as those discussed in the next section) and initiatives (e.g., increasing green/blue infrastructure) indirectly promote social connectedness is meaningful.

Most quasi-experimental evaluations of programs at adult day service centers, or “senior centers,” have shown statistically significantly greater reductions in depression symptoms and improvements in quality of life among intervention participants compared with control subjects (83). Although the impact of adult day centers depends on the specific services offered (83), bolstering these settings’ capacity to deliver evidence-based and culturally specific mental health programming may be effective in improving mental health outcomes. One example is the Positive Minds–Strong Bodies (PMSB) disability prevention intervention, a manualized and integrated mental and physical health program delivered by paraprofessionals in four languages. PMSB was found to be an acceptable form of treatment to Asian and Latinx older adults (84), and it has been implemented in community-based organizations across three states and Puerto Rico. A second example is EnhanceWellness (85), an evidence-based program currently offered by 13 community-based organizations across seven states. The personalized program connects older adults with trained coaches who assist the individual in the identification and modification of target behaviors. While the PMSB and EnhanceWellness programs differ in scale and empirical support, both have demonstrated significant improvements in mental health outcomes (e.g., decreases in depressive and anxiety symptoms, social isolation, and loneliness) as well as adequate feasibility across community sites (84–86).

Another promising area for improving older adults’ mental health is the promotion of group-based exercise (87). The EnhanceFitness program, associated with EnhanceWellness, has been nationally disseminated and shown to be effective among adults with low socioeconomic status and diverse racial/ethnic backgrounds (88). EnhanceFitness is a low-cost group exercise and fall-prevention program that has been implemented across a wide range of community-based organizations and is associated with myriad psychosocial improvements (89, 90). Stanford University’s Chronic Disease Self-Management Program has demonstrated similar results and showcases yet another example of how exercise programs can be utilized as a medium for mental health promotion among older adults (91–94). Community-based initiatives provide additional opportunities for older adults to remain socially engaged, making the group-based format of the programs particularly important to note. When considering the persistent stigma surrounding mental health, the benefit of these programs could be twofold, as they promote mental health through modalities that are more acceptable to older adults.